| Doctor Name: | ABBY WALLACE |
| NPI Number: | 1376897694 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LAPC |
| License Number: | APC003548 |
| Business Practice Address: | 1875 Fant Dr Fort Oglethorpe, GA - 307423307 |
| Business Phone Number: | 7068061169 |
| Business Fax Number: | 7068061186 |
| Mailing Address: | 1875 Fant Dr, FORT OGLETHORPE |
| State: | GA |
| Postal Code: | 307423307 |
| Phone Number: | 7068061169 |
| Fax Number: | 7068061186 |
| NPI Enumeration Date: | 11/08/2012 |
| NPI Last Update Date: | 11/08/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | APC003548 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |